What is the Patient-Driven Groupings Model (PDGM)?

The biggest change the home healthcare industry has seen in decades, Patient-Driven Groupings Model (PDGM) is now in effect. Axxess is here to help you prepare for, navigate and thrive in this changing environment. Understanding the changes will help you stay compliant and improve patient outcomes. The Centers for Medicare & Medicaid Services (CMS) is overhauling the home health prospective payment system as they continue the shift toward value-based care.

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CMS organization-Level Impact Analysis

The CMS organization-Level Impact Analysis provides an estimate of the potential impact PDGM could have on your organization. It uses data from the Centers for Medicare and Medicaid Services’ projections that were updated with final 2019 payment rates and reflects methodology changes incorporated into the Final Rule released October 31, 2018.

PDGM Related Blogs

Understanding How PDGM Changes a LUPA

One of the most significant changes the Centers for Medicare and Medicaid Services has made in the new payment model is the threshold for a Low Utilization Payment Adjustment, or LUPA.

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Your PDGM Questions Answered

As PDGM took shape, our team consumed every resource and analyzed all available data,. We put this knowledge to build state-of-the-art PDGM features into our home health software and answer more than 100 frequently asked questions.

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Decoding PDGM's Questionable Encounter Codes

The Patient-Driven Groupings Model or PDGM, has exposed a common deficit: correct use of the ICD-10-CM code set's Official Guidelines and Conventions.

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Frequently Asked Questions

For now, it only affects Medicare reimbursement. However, private insurance often follows CMS’ lead so it could eventually be adopted by managed care payers.
Most likely. Some will see positive, some neutral, and others may see negative impacts.
The areas that home health organizations need to assess are:
  • Therapy thresholds
  • LUPAs
  • Non-specific coding
  • Referral sources and the tendency for organizations to focus on institutional referrals rather than community referrals
  • 30-day billing periods
The behavioral adjustment represents a potential 6.425 percent decrease in reimbursement for changes related to LUPAs, comorbidities, and diagnosis codes.
PDGM is a billing initiative and not a clinical one. Maintenance therapy will remain a skilled service under PDGM, however, therapy thresholds will no longer apply.
Educate your staff and referral sources on PDGM. Using data analytics and impact studies, organizations can determine their PDGM risk and develop an individualized plan to mitigate their risk. Ensure that there is alignment of partnerships in coding and software vendors. Along with operational and financial changes, organizations should have a clinical refocus on intra-episode management.

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